Provider Demographics
NPI:1619647393
Name:MATA, LORRAINE MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:LORRAINE
Middle Name:MICHELLE
Last Name:MATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N EL PASO ST STE E
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-3438
Mailing Address - Country:US
Mailing Address - Phone:915-577-0445
Mailing Address - Fax:915-577-0509
Practice Address - Street 1:1400 N EL PASO ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3437
Practice Address - Country:US
Practice Address - Phone:915-577-0445
Practice Address - Fax:915-577-0509
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1039612363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics